NUR 211 FUNDAMENTALS EXAM 2
Question 1
A client is having difficulty climbing stairs and reports shortness of
breath. The nurse notes that the client is breathing heavy, having nasal
flaring and mouth is wide open. How will the nurse document this client's
response to activity?
Wheezing with activity.
Tachypnea.
Dyspnea on exertion (DOE).
Apnea.
Question 2
A home care client was recently prescribed continuous oxygen.
What client statement indicates further education is needed?
I will be able to tell how much oxygen I’m getting by looking
at the flowmeter.
I should call my doctor if I find it harder to concentrate.
I will make sure my visitors smoke outside.
I will wear synthetic clothing and woolen socks when using
my oxygen
Question 3
Which characteristics of the stages of infection indicate the full stage of
infection?
a. It is the interval between the pathogen’s invasion of the body and
the appearance of symptoms of infection.
, b. Specific signs and symptoms are present.
c. The organisms are growing and multiplying.
d. Early signs and symptoms of disease are present, but these are
often vague and nonspecific.
Question 4
While assessing the client, the nurse hears diminished lung sounds on
auscultation, counts a respiratory rate of 22 and regular, and obtains an
oxygen saturation of 89% on room air. What nursing diagnosis is best
supported by this assessment data?
a. Impaired gas exchange ??
b. Ineffective airway clearance ??
c. Anxiety
d. Tachypnea
Question 5
A nurse accidentally sticks her hand with a needle after
administering an injection to a client. What action should the nurse
take first?
a. Report the incident to the charge nurse.
b. Wash the area of the puncture thoroughly with soap and warm
water.
c. Complete an incident report.
d. Go to employee health services.
Question 6
A nurse is interviewing a client who will undergo a cardiac
coronary catheterization (angiography). The nurse inquires if
the client has someone with her that will be able to drive her
home after the procedure. What phase of the nursing process
involves questioning and gathering data?
a. Planning
b. Evaluation
c. Assessment
d. Diagnosis
, Question 7
Following shift-to-shift report, what nursing process activity is
performed first?
a. Critically analyze assessment data to determine priorities.
b. Collect and organize client data through physical assessment.
c. Set client-centered, measurable and realistic goals.
d. Determine effectiveness of intervention.
Question 8
A nurse working on an orthopedic unit is caring for four clients. What
client is at greatest risk for skin breakdown?
a. An adolescent who has a cervical fracture and is in a halo brace.
b. A young adult who has a femur fracture and is in a cast.
c. A middle adult who has a fractured radius and an arm cast.
d. An older adult who has a hip fracture and is in an immobilizer
Question 9
The nurse is assigned to care for a middle-ages adult woman who
recently had abreast removed due to cancer. While preparing to clean the
incision, the patient tells the nurse, "I just can't look at myself like this."
What is the best therapeutic response?
a. It could be worse.
b. Let me finish preparing the supplies, then we can talk.
c. I see this is a difficult change for you. Tell me more about how
you’re feeling.
d. Don’t worry, everything will be alright.
Question 10
While performing an assessment, the nurse hears crackles in bilateral
lower lung lobes. The nurse adds a nursing diagnosis of impaired gas
exchange. What purpose does a nursing diagnoses serve? (Select all that
apply.)
a. Nursing diagnoses allow for greater autonomy in the nursing field.
Question 1
A client is having difficulty climbing stairs and reports shortness of
breath. The nurse notes that the client is breathing heavy, having nasal
flaring and mouth is wide open. How will the nurse document this client's
response to activity?
Wheezing with activity.
Tachypnea.
Dyspnea on exertion (DOE).
Apnea.
Question 2
A home care client was recently prescribed continuous oxygen.
What client statement indicates further education is needed?
I will be able to tell how much oxygen I’m getting by looking
at the flowmeter.
I should call my doctor if I find it harder to concentrate.
I will make sure my visitors smoke outside.
I will wear synthetic clothing and woolen socks when using
my oxygen
Question 3
Which characteristics of the stages of infection indicate the full stage of
infection?
a. It is the interval between the pathogen’s invasion of the body and
the appearance of symptoms of infection.
, b. Specific signs and symptoms are present.
c. The organisms are growing and multiplying.
d. Early signs and symptoms of disease are present, but these are
often vague and nonspecific.
Question 4
While assessing the client, the nurse hears diminished lung sounds on
auscultation, counts a respiratory rate of 22 and regular, and obtains an
oxygen saturation of 89% on room air. What nursing diagnosis is best
supported by this assessment data?
a. Impaired gas exchange ??
b. Ineffective airway clearance ??
c. Anxiety
d. Tachypnea
Question 5
A nurse accidentally sticks her hand with a needle after
administering an injection to a client. What action should the nurse
take first?
a. Report the incident to the charge nurse.
b. Wash the area of the puncture thoroughly with soap and warm
water.
c. Complete an incident report.
d. Go to employee health services.
Question 6
A nurse is interviewing a client who will undergo a cardiac
coronary catheterization (angiography). The nurse inquires if
the client has someone with her that will be able to drive her
home after the procedure. What phase of the nursing process
involves questioning and gathering data?
a. Planning
b. Evaluation
c. Assessment
d. Diagnosis
, Question 7
Following shift-to-shift report, what nursing process activity is
performed first?
a. Critically analyze assessment data to determine priorities.
b. Collect and organize client data through physical assessment.
c. Set client-centered, measurable and realistic goals.
d. Determine effectiveness of intervention.
Question 8
A nurse working on an orthopedic unit is caring for four clients. What
client is at greatest risk for skin breakdown?
a. An adolescent who has a cervical fracture and is in a halo brace.
b. A young adult who has a femur fracture and is in a cast.
c. A middle adult who has a fractured radius and an arm cast.
d. An older adult who has a hip fracture and is in an immobilizer
Question 9
The nurse is assigned to care for a middle-ages adult woman who
recently had abreast removed due to cancer. While preparing to clean the
incision, the patient tells the nurse, "I just can't look at myself like this."
What is the best therapeutic response?
a. It could be worse.
b. Let me finish preparing the supplies, then we can talk.
c. I see this is a difficult change for you. Tell me more about how
you’re feeling.
d. Don’t worry, everything will be alright.
Question 10
While performing an assessment, the nurse hears crackles in bilateral
lower lung lobes. The nurse adds a nursing diagnosis of impaired gas
exchange. What purpose does a nursing diagnoses serve? (Select all that
apply.)
a. Nursing diagnoses allow for greater autonomy in the nursing field.
